Provena Covenant Med. Ctr. v. Dep’t of Revenue (Full Text)

Filed 8/26/08

NO. 4-07-0763

IN THE APPELLATE COURT

OF ILLINOIS

FOURTH DISTRICT

)
PROVENA COVENANT MEDICAL CENTER and
)
PROVENA HOSPITALS,
)
Plaintiffs-Appellees,
)
v.
)
THE DEPARTMENT OF REVENUE OF THE STATE
)
OF ILLINOIS; and BRIAN A. HAMER, in His Official
Honorable
)
Capacity as Director of the Illinois Department of
Patrick J. Londrigan,
)
Revenue,
Judge Presiding.
)
Defendants-Appellants.
____________________________________________________________

Appeal from
Circuit Court of
Sangamon County
No. 06MR597

PRESIDING JUSTICE APPLETON delivered the opinion of the court:

Provena Hospitals (Provena) brought an action for administrative review

of a decision by the Director of the Illinois Department of Revenue (Department) that

Provena’s property, Provena Covenant Medical Center (Covenant) in Urbana, Illinois,

did not qualify for an exemption from property taxes. The circuit court reversed the

Director’s decision, holding that Covenant was used primarily for charitable and

religious purposes and, therefore, was exempt under sections 15-65(a) and 15-40(a)(1)

of the Property Tax Code (35 ILCS 200/15-65(a), 15-40(a)(1) (West 2002)). We reverse

the circuit court’s judgment because we find no clear error in the Director’s decision.

I. BACKGROUND

Covenant is a not-for-profit, full-service, general acute-care hospital. As a

noncorporate subdivision of Provena, Covenant has no separate legal identity of its own.

Covenant is the property, and Provena is the owner. According to an organizational

chart in the record (applicant’s exhibit No. 153), Provena owns five other hospitals

besides Covenant, but those other hospitals are not at issue in this case.

Provena applied to the Champaign County Board of Review to exempt

Covenant from property taxes for 2002 on the ground that Covenant was used primarily

for charitable purposes (35 ILCS 200/15-65(a) (West 2002)). (Actually, Covenant was

nominally the applicant, but because Covenant is not a legal “person,” we consider

Provena to be the real applicant.) The board of review recommended denying the

application, and in February 2004, the Director followed that recommendation.

Provena paid $1.1 million in property taxes under protest and requested an

administrative hearing. In the hearing before the Department’s administrative law

judge (ALJ), Provena raised an additional ground for exemption besides charitable

purposes (35 ILCS 200/15-65(a) (West 2002)): it claimed that as a health-care ministry

of the Roman Catholic Church, Covenant was used primarily for religious purposes (35

ILCS 200/15-40(a)(1) (West 2002)). The ALJ submitted to the Director a decision

recommending an exemption on the sole grounds that Provena was a charitable

institution and its property, Covenant, was used primarily for charitable purposes. The

ALJ did not reach the issue of whether Covenant was used primarily for religious

purposes as well.

The Director disagreed with the ALJ’s recommendation and denied an

exemption for charitable uses. The primary reason for his decision was that in 2002, the

tax year in question, Covenant devoted only 0.7% of its total revenue to charity care. Of

110,000 admissions in 2002, Covenant gave free care to only 196 patients and dis-

counted care to only 106 patients; and Covenant hired collection agencies to recover the

remaining balances from 64 of the patients to whom it had given discounts. Without

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explanation, the Director also denied an exemption for religious uses.

Provena filed a complaint for administrative review. It argued to the

circuit court that under the supreme court’s decisions, charities were not defined by

percentages and that, in any event, Covenant dispensed an ample amount of charity to

the community in forms other than charity care. Covenant had a charity-care policy

based on federal poverty guidelines, and it advertised the availability of “financial

assistance.” According to Provena, Covenant gave this financial assistance to every

patient who needed and requested it, and the number of indigent people who walked in

through the door and availed themselves of the charity-care policy simply was beyond

Covenant’s control. Also, Provena argued, considering the meager rates of reimburse-

ment the government paid, treating Medicare and Medicaid patients was itself an act of

charity. Provena further argued–indeed, the parties had stipulated–that Covenant was

a faith-based institution founded, organized, owned, and operated as an apostolic

mission and health-care ministry of the Catholic Church. The circuit court concluded

that Covenant was entitled to both a charitable and religious exemption, and it reversed

the Director’s decision.

This appeal followed.

II. ANALYSIS

A. Standard of Review

We review the Department’s decision, not the circuit court’s decision.

Calvary Baptist Church of Tilton v. Department of Revenue, 349 Ill. App. 3d 325, 330,

812 N.E.2d 1, 4 (2004). The parties disagree on our standard of review. The Depart-

ment argues we should review its decision for clear error. Provena argues we should

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review the Department’s decision de novo. It is crucial, at the outset, to identify the

applicable standards of review, for they often determine the results on appeal–indeed, a

reviewing court does not even have the means of deciding an issue until it first identifies

the standard of review.

Formerly, the rule was that “[if] facts [were] undisputed, *** a determina-

tion of whether property [was] exempt from taxation [was] a question of law.” Chicago

Patrolmen’s Ass’n v. Department of Revenue, 171 Ill. 2d 263, 271, 664 N.E.2d 52, 56

(1996); see also City of Chicago v. Illinois Department of Revenue, 147 Ill. 2d 484, 491,

590 N.E.2d 478, 481 (1992); Harrisburg-Raleigh Airport Authority v. Department of

Revenue, 126 Ill. 2d 326, 331, 533 N.E.2d 1072, 1073 (1989). To the extent the facts

were disputed, courts decided whether the Department’s factual findings were against

the manifest weight of the evidence. Branson v. Department of Revenue, 168 Ill. 2d 247,

264, 659 N.E.2d 961, 969-70 (1995). Thus, on administrative review of the Depart-

ment’s decision to grant or deny an exemption, any given issue fell into either the

category of fact or the category of law.

In City of Belvidere v. Illinois State Labor Relations Board, 181 Ill. 2d 191,

205, 692 N.E.2d 295, 302 (1998), the supreme court identified, for the first time, a third

type of question a court could ask on administrative review: a question that was neither

purely factual nor purely legal but one of fact and law mixed together. The supreme

court decided that because the case required “an examination of the legal effect of a

given set of facts, it [presented] a mixed question of fact and law” and the supreme court

would review the agency’s decision for clear error (City of Belvidere, 181 Ill. 2d at 205,

692 N.E.2d at 302)–not de novo, as the supreme court previously had held.

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Later, in Eden Retirement Center, Inc. v. Department of Revenue, 213 Ill.

2d 273, 284, 821 N.E.2d 240, 246 (2004), the supreme court seemed to revert to the

former rule: it prescribed a de novo standard of review when the facts were undisputed

and the only issue was whether the property was exempt. The supreme court stated:

“[T]he Department’s decision as to whether [the] plaintiff’s property is exempt from

taxation depends solely on the application of the appropriate legal standard to the

undisputed facts, which is a question of law.” Accordingly, in a recent property-tax

exemption case, we dutifully echoed the supreme court: ” ‘[T]he Department’s decision

as to whether [the] plaintiff’s property is exempt from taxation depends solely on the

application of the appropriate legal standard to the undisputed facts, which is a question

of law.’ ” Faith Builders Church, Inc. v. Department of Revenue, 378 Ill. App. 3d 1037,

1043, 882 N.E.2d 1256, 1261 (2008), appeal denied, 228 Ill. 2d 531, 889 N.E.2d 1115

(2008), quoting Eden Retirement Center, 213 Ill. 2d at 284, 821 N.E.2d at 246.

Soon after our decision in Faith Builders, the supreme court issued a

decision in which it reaffirmed the three different standards of review in administrative-

review cases: manifest weight of the evidence for questions of fact, de novo for ques-

tions of law, and clear error for questions of fact and law mixed together. Cinkus v.

Village of Stickney Municipal Officers Electoral Board, 228 Ill. 2d 200, 210-11, 886

N.E.2d 1011, 1018 (2008). In the third type of question–a question that was simulta-

neously legal and factual–” ‘ “the historical facts [were] admitted or established, the rule

of law [was] undisputed, and the issue [was] whether the facts satisf[ied] the statutory

standard, or[,] to put it another way, whether the rule of law as applied to the estab-

lished facts [was] or [was] not violated.” ‘ ” Cinkus, 228 Ill. 2d at 211, 886 N.E.2d at

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1018, quoting American Federation of State, County & Municipal Employees, Council 31

v. State Labor Relations Board, 216 Ill. 2d 569, 577, 839 N.E.2d 479, 485 (2005),

quoting Pullman-Standard v. Swint, 456 U.S. 273, 289 n.19, 72 L. Ed. 2d 66, 80 n.19,

102 S. Ct. 1781, 1790 n.19 (1982). Manifest weight of the evidence would be an insuffi-

cient concept to bring to such a hybrid question, for evidence relates only to facts and

the question is one of law as much as fact. Also, the legal aspect of the question calls for

somewhat less deference than if the question were purely factual. Carpetland U.S.A.,

Inc. v. Illinois Department of Employment Security, 201 Ill. 2d 351, 369, 776 N.E.2d 166,

177 (2002). On a continuum of deference, clear error is located between manifest

weight and de novo. Carpetland U.S.A., 201 Ill. 2d at 369, 776 N.E.2d at 177; see also Du

Page County Board of Review v. Department of Revenue, 339 Ill. App. 3d 230, 234, 790

N.E.2d 918, 922 (2003) (remarking that, in practice, the difference between these

degrees of deference can be subtle). “[A]n administrative agency’s decision is deemed

‘clearly erroneous’ when the reviewing court is left with the ‘ “definite and firm convic-

tion that a mistake has been committed.” ‘ ” Cinkus, 228 Ill. 2d at 211, 886 N.E.2d at

1018, quoting AFM Messenger Service, Inc. v. Department of Employment Security, 198

Ill. 2d 380, 395, 763 N.E.2d 272, 282 (2001), quoting United States v. United States

Gypsum Co., 333 U.S. 364, 395, 92 L. Ed. 746, 766, 68 S. Ct. 525, 542 (1948).

The supreme court acknowledged, in Cinkus, 228 Ill. 2d at 211, 886 N.E.2d

at 1019, that the distinction between these three different standards of review “ha[d] not

always been apparent in [its] case law”; and–significantly for our purposes–the

supreme court cited Eden Retirement Center as an example of a case in which the

distinction was not apparent (Cinkus, 228 Ill. 2d at 211, 886 N.E.2d at 1019). It follows

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that Eden Retirement Center, on which Provena relies and on which we relied in Faith

Builders, no longer is sound authority with respect to the standard of review in

administrative-review cases in which the facts are undisputed and the law is to be

applied to those facts. (Of course, since we upheld the Department’s decision in Faith

Builders, the same result would have followed in that case under the more deferential

clear-error standard of review.)

The facts in the present case are undisputed, and the question before us is

whether those facts entitle Covenant to an exemption under section 15-65(a) or 15-

40(a)(1) (35 ILCS 200/15-65(a), 15-40(a)(1) (West 2002)). We conclude, from Cinkus,

that we should review the Department’s decision for clear error. See also Calvary

Baptist Church of Tilton, 349 Ill. App. 3d at 330, 812 N.E.2d at 5; Three Angels Broad-

casting Network, Inc. v. Department of Revenue, 381 Ill. App. 3d 679, 693, 885 N.E.2d

554, 567 (2008); Illinois Beta House Fund Corp. v. Department of Revenue, 382 Ill.

App. 3d 426, 429, 887 N.E.2d 847, 849-50 (2008); Du Page County Airport Authority v.

Department of Revenue, 358 Ill. App. 3d 476, 484, 831 N.E.2d 30, 38 (2005).

Of course, we can apply more than one standard of review in an appeal,

depending on the issue under consideration. Insomuch as the parties disagree on the

meaning of legislation or case law, we resolve the disagreement de novo. See Cinkus,

228 Ill. 2d at 210, 886 N.E.2d at 1018; City of Belvidere, 181 Ill. 2d at 205, 692 N.E.2d at

302. The cases make an exception for ambiguous statutes that the agency administers:

we defer to the agency’s interpretation of the ambiguous statute if the interpretation is

reasonable. Illinois Bell Telephone Co. v. Illinois Commerce Comm’n, 362 Ill. App. 3d

652, 657, 840 N.E.2d 704, 709 (2005).

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B. The Exemption for Charitable Purposes

1. Ownership By an Institution of Public Charity

Provena had the burden of proving, ” ‘clearly and conclusively,’ ” its

entitlement to the claimed exemptions (Illini Media Co. v. Department of Revenue, 279

Ill. App. 3d 432, 435, 664 N.E.2d 706, 709 (1996), quoting Chicago Bar Ass’n v. Depart-

ment of Revenue, 163 Ill. 2d 290, 300, 644 N.E.2d 1166, 1171 (1994)), and the Director

has to resolve all debatable questions in favor of taxation without giving an ” ‘ “unrea-

sonably narrow” ‘ ” construction to the statute (see Illini Media, 279 Ill. App. 3d at 435,

664 N.E.2d at 709, quoting People ex rel. Goodman v. University of Illinois Foundation,

388 Ill. 363, 370, 58 N.E.2d 33, 37 (1944), quoting People ex rel. Pearsall v. Catholic

Bishop of Chicago, 311 Ill. 11, 16, 142 N.E. 520, 522 (1924)). One of the reasons why the

Director denied an exemption under section 15-65(a) (35 ILCS 200/15-65(a) (West

2002)) was Provena’s failure to prove, clearly and conclusively, that it was a charitable

institution. Section 15-65(a) requires that the property in question–in this case,

Covenant–be the “property of” an “institution of public charity.” 35 ILCS 200/15-65(a)

(West 2002). The statute provides:

“All property of the following is exempt when actually

and exclusively used for charitable or beneficent purposes[]

and not leased or otherwise used with a view to profit:

(a) Institutions of public charity.” 35

ILCS 200/15-65(a) (West 2002).

By contrast, section 6 of article IX of the Illinois Constitution, on its face,

does not require ownership by a charitable organization; it merely requires that the

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property be “used exclusively for *** charitable purposes.” Ill. Const. 1970, art. IX, §6.

It provides:

“The General Assembly by law may exempt from

taxation only the property of the [s]tate, units of local gov-

ernment and school districts[,] and property used exclusively

for agricultural and horticultural societies[] and for school,

religious, cemetery[,] and charitable purposes. The General

Assembly by law may grant homestead exemptions or rent

credits.” Ill. Const. 1970, art. IX, §6.

While section 6 of article IX gives the General Assembly a choice whether

to exempt the classes of property listed therein (saying the General Assembly “may” do

so), it permits the General Assembly to exempt “only” those classes of property. Ill.

Const. 1970, art. IX, §6. Thus, the General Assembly may not broaden or add to the

exemptions that section 6 of article IX allows. International College of Surgeons v.

Brenza, 8 Ill. 2d 141, 145-46, 133 N.E.2d 269, 272 (1956). Because the General Assem-

bly, however, may decline to grant exemptions altogether, the General Assembly, by

corollary, may restrict or limit any exemption over and above the restrictions or

limitations in section 6 of article IX. North Shore Post No. 21 of the American Legion v.

Korzen, 38 Ill. 2d 231, 233, 230 N.E.2d 833, 835 (1967). (North Shore Post No. 21

predates the 1970 Illinois Constitution. Nevertheless, section 6 of article IX of the 1970

Illinois Constitution is merely a rephrasing of the corresponding provision, section 3 of

article IX, of the 1870 Illinois Constitution (Ill. Const. 1870, art. IX, §3), and cases

interpreting the provision in the 1870 constitution continue to be relevant. Eden

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Retirement Center, 213 Ill. 2d at 286, 821 N.E.2d at 247.)

Thus, in addition to the constitutional requirement that the property be

used exclusively for charitable purposes, the General Assembly has set down a further

requirement for the exemption: the property must be owned by an “institution[] of

public charity.” 35 ILCS 200/15-65(a) (West 2002); Chicago Patrolmen’s Ass’n v.

Department of Revenue, 171 Ill. 2d 263, 270, 664 N.E.2d 52, 55-56 (1996); Most

Worshipful Grand Lodge of Ancient Free & Accepted Masons of the State of Illinois v.

Department of Revenue, 378 Ill. App. 3d 1069, 1075, 884 N.E.2d 1168, 1173 (2007).

Under section 15-65(a), it will not suffice that the property is “exclusively used for

charitable or beneficent purposes” (“beneficent” is synonymous with “charitable”

(People ex rel. Nelson v. Rockford Lodge No. 64, Benevolent & Protective Order of Elks,

348 Ill. 528, 531, 181 N.E. 432, 433 (1932)); the owner of the property must be a

charitable organization. Chicago Patrolmen’s Ass’n, 171 Ill. 2d at 270, 664 N.E.2d at 55-

56).

In Methodist Old Peoples Home v. Korzen, 39 Ill. 2d 149, 157, 233 N.E.2d

537, 541-42 (1968), the supreme court listed six “distinctive characteristics of a charita-

ble institution”: (1) the institution bestows benefits upon an indefinite number of

persons for their general welfare, or the benefits in some way reduce the burdens on

government; (2) the institution has no capital, capital stock, or shareholders and does

not profit from the enterprise; (3) the funds of the institution are derived mainly from

private and public charity and are held in trust for the purposes expressed in the

charter; (4) charity is dispensed to all who need it and apply for it; (5) the institution

puts no obstacles in the way of those seeking the charitable benefits; and (6) the primary

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use of the property is for charitable purposes. See also Eden Retirement Center, 213 Ill.

2d at 287, 821 N.E.2d at 248 (deriving those six factors from Methodist Old Peoples

Home); Most Worshipful Grand Lodge, 378 Ill. App. 3d at 1075, 884 N.E.2d at 1173

(same).

Courts also have applied the six factors to the issue of charitable use, i.e.,

whether the property was “exclusively used for charitable or beneficent purposes” (35

ILCS 200/15-65(a) (West 2006)). Eden Retirement Center, 213 Ill. 2d at 287, 821

N.E.2d at 248; Most Worshipful Grand Lodge, 378 Ill. App. 3d at 1075, 884 N.E.2d at

1173; Lutheran General Health Care System v. Department of Revenue, 231 Ill. App. 3d

652, 657, 595 N.E.2d 1214, 1218 (1992). The factors lend themselves more readily to

assessing the charitable nature of the owner–indeed, the supreme court originally

described the factors as the “distinctive characteristics of a charitable institution”

(Methodist Old Peoples Home, 39 Ill. 2d at 157, 233 N.E.2d at 541). Applying the six

factors to the question of charitable use can be awkward if only because the sixth factor

squarely poses the question of charitable use (Eden Retirement Center, 213 Ill. 2d at

287, 821 N.E.2d at 248 (“(6) *** exclusive, i.e., primary, use of the property is for

charitable purposes”)), suggesting that the preceding five factors address some other

question. Nevertheless, some of the factors do describe how property is used for

charitable purposes, i.e., bestowing benefits upon an indefinite number of persons,

lessening the burdens on government, dispensing charity to all who need it and apply

for it, and putting no obstacles in their way (Methodist Old Peoples Home, 39 Ill. 2d at

157, 233 N.E.2d at 541-42).

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Part of the difficulty with the factors in Methodist Old Peoples Home (and,

for that matter, with any set of factors) is discerning how important any one factor is

compared to another. The First District has said that “[t]he factors outlined by the

supreme court in [Methodist Old Peoples Home] are guidelines rather than definitive

requirements.” Arts Club of Chicago v. Department of Revenue, 334 Ill. App. 3d 235,

243, 777 N.E.2d 700, 707 (2002). That cannot be correct. Some of the factors are more

than guidelines. The sixth factor is that the property be used exclusively for charitable

purposes, and under the constitution and statute, exclusive use for charitable purposes

is the sine qua non of the exemption (Ill. Const. 1970, art. IX, §6; 35 ILCS 200/15-65(a)

(West 2006)). The supreme court has called the factors “guidelines or criteria.” Eden

Retirement Center, 213 Ill. 2d at 287, 821 N.E.2d at 248. Apparently, the only way of

telling which factors are guidelines and which are essential criteria is to see how they are

treated in case law. The factors are old–Methodist Old Peoples Home dates from 1968,

and it relied on cases going back 75 years (Methodist Old Peoples Home, 39 Ill. 2d at

156-57, 233 N.E.2d at 541-42)–and it appears that one of the factors at issue, namely,

charitable funding of the institution (Eden Retirement Center, 213 Ill. 2d at 287, 821

N.E.2d at 248), has waned in importance. But the other factors, or at least the ones at

issue in this appeal, still seem to be in force.

If we credit the Department’s argument, it would not matter that some of

the factors had grown obsolete, for, according to the Department, Provena satisfies only

one of the six factors: it has no capital, capital stock, or shareholders, and, as a corpora-

tion, it does not profit from the enterprise (see Methodist Old Peoples Home, 39 Ill. 2d

at 157, 233 N.E.2d at 541). Clearly, not-for-profit status alone does not confer an

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exemption under section 15-65(a). Eden Retirement Center, 213 Ill. 2d at 290, 821

N.E.2d at 250; People ex rel. County Collector v. Hopedale Medical Foundation, 46 Ill.

2d 450, 464, 264 N.E.2d 4, 11 (1970). We will consider the remaining five factors in

turn.

a. Benefits to an Indefinite Number of People for Their
General Welfare So as To Reduce the Burdens on Government

The first factor from Methodist Old Peoples Home is that “the benefits

derived are for an indefinite number of persons for their general welfare or [they] in

some way reduc[e] the burdens on government.” Eden Retirement Center, 213 Ill. 2d at

287, 821 N.E.2d at 248. This factor is more than a guideline; it describes what a charity

essentially is. “The fundamental ground upon which all exemptions in favor of charita-

ble institutions are based is the benefit conferred upon the public by them and a

consequent relief, to some extent, of the burden upon the State to care for[,] and

advance the interests of[,] its citizens.” School of Domestic Arts & Science v. Carr, 322

Ill. 562, 569, 153 N.E. 669, 671 (1926); see also In re Estate of Graves, 242 Ill. 23, 28, 89

N.E. 672, 674 (1909) (“It would clearly be within the province of the park commission-

ers to erect drinking fountains or basins for horses” such as the one the testator pro-

vided for by charitable bequest). To be for a charitable use or purpose, the gift must be a

public, rather than a private, gift (14 C.J.S. Charities §10, at 182 (2006); Restatement

(Second) of Trusts §§375, 376, (1959)); it must be “‘general benevolence'” rather than

” ‘personal bounty to particular individuals’ ” (Saltonstall v. Sanders, 93 Mass. (11 Allen)

446, 466 (1865), quoting Attorney General v. Comber, 2 Sim. & Stu. 93 (1824)). For

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example, “[a] gift to poor relations or for their benefit is a private gift, although it would

prevent their becoming a public charge.” 14 C.J.S. Charities §13, at 185 (2006).

Obviously, Provena–basically, a conglomerate of hospitals–was not

formed to bestow a private gift upon particular individuals, such as “poor relations.” It

is far from obvious, however, that Provena is a gift to the public. As we will discuss at

greater length below, it is unclear to what extent Provena exercises “general benevo-

lence” as opposed to doing what a for-profit hospital does: selling medical services.

Provena argues it lessens the burdens of government because if not for the existence of

Covenant, Champaign County would have to build a hospital. The supreme court has

held, however, that “services extended *** for value received *** do not relieve the

[s]tate of its burden.” Willows v. Munson, 43 Ill. 2d 203, 208, 251 N.E.2d 249, 252

(1969). See also People ex rel. Nordlund v. Ass’n of the Winnebago Home for the Aged,

40 Ill. 2d 91, 101, 237 N.E.2d 533, 539 (1968); 14 C.J.S. Charities §3, at 177 (2006)

(“Whatever is gratuitously done for the advancement of the public good is a public

charity”); D. Hyman, The Conundrum of Charitability: Reassessing Tax Exemption for

Hospitals, 16 Am. J.L. & Med. 327, 378 (1990) (“Reduced to its elements, one must

simply be in the hospital ‘business’ and not distribute any profit in order to meet the

liberal test [for exemption]. This is rather curious because *** for-profit hospitals are

also in the hospital business. The inurement constraint alone is not sufficient reason to

grant favorable tax treatment to one institution and not the other”).

b. Funds Derived Mainly From Private and Public Charity

The third factor from Methodist Old Peoples Home (again, the second

factor is not at issue) is that “funds are derived mainly from private and public charity[]

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and the funds are held in trust for the objects and purposes expressed in the organiza-

tion’s charter.” Eden Retirement Center, 213 Ill. 2d at 287, 821 N.E.2d at 248.

The Director stated in his decision:

“[I]f we look at the financial picture of Covenant’s

parent, we see that for Provena Hospital’s year end[ing]

December 31, 2002, [the] ‘Consolidated Statement of Opera-

tions Information’ shows other revenue of $25,382,000,

which is 3.4% of total revenue of $739,293,000. It is impos-

sible to tell how much of the 3.4% of other revenue [was]

derived from public and private charity because there is no

further breakdown of this amount in the statement. [Cita-

tion to record.] As discussed previously, the record in this

case is very limited in evidence concerning how Provena

Hospitals, the owner of the property, qualifies as a charitable

organization. If the entire 3.4% of ‘other revenue’ in Provena

Hospital’s statement was derived from public and private

charity, I still would not be able to conclude that Provena

Hospitals meets the [Methodist Old Peoples Home] guide-

line that it derives its funds mainly from public and private

charity.”

In American College of Surgeons v. Korzen, 36 Ill. 2d 340, 348, 224

N.E.2d 7, 11 (1967), overruled on other grounds by Christian Action Ministry v. Depart-

ment of Local Government Affairs, 74 Ill. 2d 51, 57, 383 N.E.2d 958, 961 (1978), the

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taxing authority argued that the college was not a charitable organization because

approximately half of its funds came from members’ dues. The supreme court held:

“A careful reading of the cases indicates that while the

source of funds is listed as a characteristic of a charitable

organization, each [case] concerns itself primarily with

discovery of the facts relative to the use to which the funds

are put. *** [W]here it is established that the funds and

property are devoted to public purposes, the source of the

funds is not the sole determinant factor.” American College,

36 Ill. 2d at 348, 224 N.E.2d at 11.

It appears that funding by charitable donations can help to establish the identity of an

institution as charitable (Eden Retirement Center, 213 Ill. 2d at 287, 821 N.E.2d at 248;

J. Colombo, Hospital Property Tax Exemption in Illinois: Exploring the Policy Gaps, 37

Loy. U. Chi. L.J. 493, 519 (2006)) but such funding is not essential (American College,

36 Ill. 2d at 348, 224 N.E.2d at 11). “Recent data shows that, overall, nonprofit hospitals

receive less than 2% of their revenues from private philanthropy.” 37 Loy. U. Chi. L.J. at

520. Making the absence of such funding dispositive would effectively end the charita-

ble exemption for nonprofit hospitals. 37 Loy. U. Chi. L.J. at 520. In Sisters of the

Third Order of St. Francis v. Board of Review, 231 Ill. 317, 321, 83 N.E. 272, 273 (1907),

the supreme court seemed to approve of a hospital’s practice of subsidizing the medical

care of the poor by charging patients who were able to pay. But see M. Bloche, Health

Policy Below the Waterline: Medical Care and the Charitable Exemption, 80 Minn. L.

Rev. 299, 355 (1995) (“the imagery of charity rings hollow when it comes to hospitals.

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Most obviously, the free care provided by nonprofit hospitals is financed largely by

private payers, who are hardly inspired by donative benevolence”); 37 Loy. U. Chi. L.J.

at 519 (theoretically, “donations are an excellent ‘signal’ that the public views a particu-

lar entity as undertaking charitable activities,” and, therefore, “an excellent conceptual

reason exists to use donations as a measure of an entity’s ‘charitable-ness’ “). Thus,

having an operating income derived almost entirely from contractual charges goes

against a charitable identity (Small v. Pangle, 60 Ill. 2d 510, 517, 328 N.E.2d 285, 288-

89 (1975)), but this factor, by itself, is not dispositive (American College, 36 Ill. 2d at

348, 224 N.E.2d at 11).

c. Providing Charity to All Who Need It and Apply for It and
Refraining from Interposing Any Obstacles to Such Charity

The fourth factor from Methodist Old Peoples Home is that “charity is

dispensed to all who need [it] and apply for it,” and the fifth factor, closely related to the

preceding one, is that “no obstacles are placed in the way of those seeking the benefits.”

Eden Retirement Center, 213 Ill. 2d at 287, 821 N.E.2d at 248. The Director found as

follows:

“*** I find that the record contains no information as

to Provena Hospital’s charitable expenditures in 2002.

According to the ALJ in her Recommendation for Disposi-

tion, ‘[t]he testimony indicated, and the advertisements,

collection practices, and other documents support the find-

ing[,] that Covenant’s policies and practices are the same as

those of the owner of the property,’ Provena Hospitals.

– 17 –

[Citation to ALJ’s recommended decision.] Without infor-

mation about Provena’s expenditures for charitable care in

2002, it is not possible to conclude that the true owner of the

property is a charitable institution[,] as required by Illinois

law.”

A charity dispenses charity and does not obstruct the path to its charitable

benefits. Eden Retirement Center, 213 Ill. 2d at 287, 821 N.E.2d at 248. Provena and

the amici curiae disagree with the Department on the meaning of ” ‘charity.’ ” As one of

the amici curiae, the Illinois Hospital Association, observes, “charity” can have different

meanings depending on whether an article precedes it: a charity is an organization,

whereas charity is what the organization dispenses. Quoting Methodist Old Peoples

Home, 39 Ill. 2d at 156, 233 N.E.2d at 541, the Department argues that “charity is a gift”

and unless we know how much charity care Provena provides through its six hospitals,

we cannot make a valid generalization that Provena is a charitable institution. The

Illinois Hospital Association argues the Department is distorting the meaning of

Methodist Old Peoples Home by omitting, from its quotation of that case, the indefinite

article that precedes “charity”: the supreme court said, in Methodist Old Peoples Home,

39 Ill. 2d at 156, 233 N.E.2d at 541, that “a charity is a gift” (emphasis added). The

phrase comes ultimately from a Massachusetts case, which the supreme court first

quoted in Crerar v. Williams, 145 Ill. 625, 34 N.E. 467 (1893), as follows:

“A comprehensive legal definition of a charity, or

charitable use, is given by Gray, J., in Jackson v. Phillips, 14

Allen, 556 (approved by Perry in his work on Trusts, vol. 2,

– 18 –

sec. 697) as follows: ‘A charity, in [the] legal sense, may be

more fully defined as a gift, to be applied consistently with

existing laws, for the benefit of an indefinite number of

persons, either by bringing their *** hearts under the influ-

ence of education or religion[;] by relieving their bodies from

disease, suffering[,] or constraint[;] by assisting them to

establish themselves [in] life[;] or by erecting or maintaining

public buildings or works[] or otherwise lessening the

burthens of government. It is immaterial whether the pur-

pose is called charitable in the gift itself, if it is so described

as to show that it is charitable in its nature.’ ” (Emphases

added.) Crerar, 145 Ill. at 643, 34 N.E. at 470, quoting Jack-

son v. Phillips, 96 Mass. (14 Allen) 539, 556 (1867).

According to the Illinois Hospital Association, the phrase “a charity is a

gift” has to do solely with how a charitable organization comes into existence–by some

person or group of persons making a charitable gift to the community for the purpose of

establishing a hospital–and does not require that the charity, after its inception, give

anything away. Provena argues it is a charitable organization because it provides

medical care, which, according to Crerar, is a charitable purpose–” ‘relieving *** bodies

from disease, suffering[,] or constraint.’ ” Crerar, 145 Ill. at 643, 34 N.E. at 470, quoting

Jackson, 96 Mass. (14 Allen) at 556.

By the logic of Provena and the Illinois Hospital Association, the only

giving that matters, for purposes of charity, is the gift by which the founders established

– 19 –

the hospital, whenever that occurred. A hospital thereafter could practice economic

predation and nevertheless maintain its charitable status. It seems to us that confining

the gift to the establishment of the hospital would make the gift dubious. If a patient,

like virtually all the other patients, must agree to pay for his or her medical care, the

patient receives a gift only in the rarefied form of an opportunity to purchase medical

care locally. A new Wal-Mart would be a gift in a comparable sense–with the added

bonus that it would pay property taxes. And if the medical bill includes a charge for the

depreciation of assets, the gift becomes even more tenuous. Unlike Wal-Mart, a not-for-

profit hospital would plow any profits back into the hospital, becoming bigger and better

equipped. But, again, from the perspective of paying patients, the gift merely would be

the enhanced opportunities to enter into increasingly expensive contractual relation-

ships with the hospital and its physicians. In Crerar, 145 Ill. at 643-44, 34 N.E. at 470, a

case Provena cites for the proposition that relieving bodies from suffering is, per se,

charity, the testator made “a gift ‘for the erection, creation, maintenance[,] and endow-

ment of a free public library.’ ” (Emphasis added.)

If medical care, free or not, were charity in and of itself, the only difference

between a charitable hospital and a for-profit hospital would be the “inurement con-

straint” (16 Am. J.L. & Med. at 378), and the supreme court made clear in Hopedale

Medical Foundation, 46 Ill. 2d at 464, 264 N.E.2d at 11 (discussing federal and state

exemptions based on inurement), that the inurement constraint implicit in the exemp-

tion from federal and state income taxation alone will not exempt a hospital from

property taxation. One commentator asks rhetorically, “Would one ever allow a dry

– 20 –

cleaner or shoe store with an inurement prohibition to qualify for tax exemption?” 16

Am. J.L. & Med. at 378.

By holding medical care to be, in and of itself, charity, we effectively would

excuse charitable hospitals from their ongoing mission of giving. We would hold that a

hospital is being charitable, for instance, when it sends an impoverished patient a bill

that the patient could never hope to pay. That holding not only would create a deafen-

ing cognitive dissonance, but it would ignore the supreme court’s repeated rationale in

cases involving charitable hospitals. If, as Provena claims, charity did not entail treating

patients for free, a case the supreme court decided only a year after Sisters of the Third

Order would make no sense. In German Hospital of Chicago v. Board of Review, 233 Ill.

246, 248-50, 84 N.E. 215, 216 (1908), the supreme court emphasized the number of

patients the hospital treated for free or at reduced rates and, on that basis, held Sisters

of the Third Order to be directly on point and the hospital to be a public charity exempt

from taxation.

Provena interprets Sisters of the Third Order as meaning that the number

of charity care patients does not matter. We do not read the case that way. In Sisters of

the Third Order, 231 Ill. at 322, 83 N.E. at 273-74, the Board of Review of Peoria County

argued that St. Francis Hospital was not an institution of public charity because of “the

great disparity between the number of charity patients and those who pay for the care

and attention they receive at this institution.” If Provena were correct–if all a charitable

hospital had to do was provide medical care because medical care was, ipso facto,

charity–the supreme court surely would have answered the board of review’s argument

by saying it did not matter how many patients St. Francis Hospital treated for free

– 21 –

because all medical care, compensated or not, was charity. But that is not what the

supreme court said. Rather, it said: “This objection seems to us without merit, so long

as charity was dispensed to all those who needed it and who applied therefor ***.”

Sisters of the Third Order, 231 Ill. at 322, 83 N.E. at 274. Clearly, in this context,

“charity” does not mean compensated medical care; it means uncompensated medical

care. Further, the corollary seems to be that if St. Francis Hospital had failed to provide

free treatment to those who needed it and applied for it, the board of review’s objection

would have had merit: the hospital would not have been an institution of public charity.

In Winnebago Home, the unsuccessful applicant for exemption was, like

Provena, in the business of relieving bodies from disease, suffering, and constraint.

“Upon accepting a resident, the association obligate[d] itself to provide him with a

home, medical care, food, and, according to the testimony of one witness, a ‘Christian

burial.’ ” Winnebago Home, 40 Ill. 2d at 97-98, 237 N.E.2d at 537. If Provena were

correct–if relieving bodies from disease, suffering, and constraint qualified as charity

even though the relieving resulted in a bill for the persons getting relieved–the defen-

dant in Winnebago Home would have received an exemption. But that is not what

happened. The supreme court held:

“[The] [d]efendant’s insistence upon the payment of a

sizable admission fee, the assignment by a resident of his

assets[,] and the health requirements imposed[] constitute

an even more serious impediment to the tax exempt status it

seeks. We find that these provisions cannot be reconciled

with our requirements of the application of benefits to an

– 22 –

indefinite number of people, dispensing charity to all who

need and apply for it[,] and not appearing to place obstacles

of any character in the way of those who need and would

avail themselves of the benefits defendant provides.”

Winnebago Home, 40 Ill. 2d at 101, 237 N.E.2d at 539.

Like Provena, the defendant in Winnebago Home, 40 Ill. 2d at 101-02, 237 N.E.2d at

539, compared itself to St. Francis Hospital in Sisters of the Third Order and Southern

Illinois Hospital in People ex rel. Cannon v. Southern Illinois Hospital Corp., 404 Ill. 66,

88 N.E.2d 20 (1949). But the supreme court rejected the comparison precisely because

“in the case of the hospitals[,] many impoverished persons were readily admitted and

cared for without charge.” (Emphasis added.) Winnebago Home, 40 Ill. 2d at 102, 237

N.E.2d at 539. These words do not leave us with the impression that the supreme court

is indifferent about the number of impoverished persons an allegedly charitable

organization serves free of charge. If, as Provena and the Illinois Association of Hospi-

tals maintain, medical care is, per se, charity and the medical care does not have to be

free because the only gift that matters is the gift establishing the hospital, the supreme

court would not have distinguished Sisters of the Third Order and Cannon by observing

that in those cases, “many” patients were “cared for without charge.” See also Willows,

43 Ill. 2d at 208, 251 N.E.2d at 252 (contrasting “dispensing charity” with selling

services). Also, the supreme court would not have minded that the defendant in

Winnebago Home had “allocated from its sizable holdings only sufficient funds to

provide for one needy applicant.” Winnebago Home, 40 Ill. 2d at 102, 237 N.E.2d at

539-40.

– 23 –

We conclude that not only is a charity a gift (Quad Cities Open, Inc. v. City

of Silvis, 208 Ill. 2d 498, 510-11, 804 N.E.2d 499, 507 (2004)) but that charity is a gift

(People ex rel. Ryan v. World Church of the Creator, 198 Ill. 2d 115, 128, 760 N.E.2d 953,

961 (2001); Ould v. Washington Hospital for Foundlings, 95 U.S. 303, 311, 24 L. Ed.

450, 451 (1877)). “Charity” is an act of kindness or benevolence. Graves, 242 Ill. at 27,

89 N.E. at 673. There is nothing particularly kind or benevolent about selling somebody

something. “Charity” is “generosity and helpfulness[,] esp[ecially] toward the needy or

suffering” (Merriam-Webster’s Collegiate Dictionary 192 (10th ed. 2000))–not merely

helpfulness, note, but generosity. “Generosity” means “liber[ality] in giving.” Merriam-

Webster’s Collegiate Dictionary 484 (10th ed. 2000). To be charitable, an institution

must give liberally. Removing giving from charity would debase the meaning of charity,

and we resist such an assault upon language. See C. Borek, Decoupling Tax Exemption

for Charitable Organizations, 31 Wm. Mitchell L. Rev. 183, 187 (2004) (“the ‘legal’

meaning [of ‘charitable’] has so stretched the term beyond its etymological boundaries

as to render the concept vacant, unoccupied by any useful legal notion of what ‘charita-

ble’ means”). The fourth and fifth factors in Methodist Old Peoples Home–dispensing

charity to all who need it and apply for it and placing no obstacles in their way–are

more than guidelines; they are essential criteria; they go to the heart of what it means to

be a charitable institution.

As the Director observed, the record appears to contain no evidence of the

amount of charity that Provena dispensed in 2002. Insomuch as the Director found this

deficiency of proof to be fatal to Provena’s status as a charitable institution, we are not

left with a definite and firm conviction that he was mistaken.

– 24 –

2. “Exclusive” Use of the Property for Charitable Purposes

a. The Impossibility of Making a Gift, and Thereby Performing Charity,
Without Foregoing Compensation for the Thing Given

Provena admits that “charity is a ‘gift.’ ” (Provena puts the word in

quotation marks.) But Provena contends that “[the] ‘gift’ is not limited, as the Depart-

ment claims, to free goods or services.” (Emphasis in original.)

On the contrary, a gift is, by definition, free goods or services: “something

voluntarily transferred by one person to another without compensation” (Merriam-

Webster’s Collegiate Dictionary 491 (10th ed. 2000)). Defining “gift” in any other way

would do violence to the meaning of the word. One can make a gift by charging nothing

at all. Or one can make a gift by undercharging a person, that is, charging less than

one’s cost (using cost as a baseline prevents the creation of an artificial gift through

inflation of prices (37 Loy. U. Chi. L.J. at 511-12)), and in that case, part of the goods or

services is given without compensation. See German Hospital, 233 Ill. at 248, 84 N.E. at

216 (“a large proportion of the entire number of patients received are treated either free

or at less than actual cost”).

Provena quotes People v. Young Men’s Christian Ass’n of Chicago, 365 Ill.

118, 122, 6 N.E.2d 166, 169 (1936): “‘Charity,’ in law, is not confined *** to mere

almsgiving.” That is true. But it is confined to giving. Charity is a gift, and one can give

a gift to a rich person as well as to a poor person, the object being “the improvement and

promotion of the happiness of man.” Congregational Sunday School & Publishing

Society v. Board of Review, 290 Ill. 108, 113, 125 N.E. 7, 9-10 (1919). For example, out of

kindness and benevolence, one could build a water fountain in a park, and rich and poor

– 25 –

alike could come and drink. But the designation of “charity” would be problematic if the

water fountain were coin-operated. Regardless of whether the recipient of the goods or

services is rich or poor or somewhere in between, it is nonsensical to say one has given a

gift to that person, or that one has been charitable, by billing that person for the full cost

of the goods or services–whether the goods or services be medical or otherwise. For a

gift (and, therefore, charity) to occur, something of value must be given for free.

In the cases on which Provena relies–Young Men’s Christian Ass’n; Quad

Cities Open; Cannon; and Sisters of the Third Order–the institutions claiming a tax

exemption charged fees as a means of financing charity care and other charitable gifts,

or they charged fees no higher than the poor could afford. In Young Men’s Christian

Ass’n, 365 Ill. at 123-24, 6 N.E.2d at 170, the supreme court said:

“The rates [the Young Men’s Christian Association of Chi-

cago] charged for its rooms are not based, alone, on the cost

of the service rendered, but the object of the appellee is to

furnish wholesome living conditions to young men at a price

they can afford to pay and thereby correct the social evils

that surround men who would otherwise be compelled to live

in cheap rooming houses, amid sordid environments.”

The record appears to contain no evidence that, in 2002, Covenant billed its patients

only as much as they could afford to pay or that Covenant was, financially or otherwise,

a kinder and gentler alternative to for-profit hospitals. See J. Colombo, The Role of

Access in Charitable Tax Exemption, 82 Wash. U. L.Q. 343, 344 (2004) (“a number of

empirical studies *** generally have found that *** private nonprofit, tax-exempt

– 26 –

hospitals do not operate much differently from for-profit counterparts in similar

geographic areas. These studies confirm that the levels of ‘uncompensated care’ differ

little between exempt and for-profit providers; that the range of services provided by

both are similar; and that under current measures of quality assessment[,] there is little

difference between the two”).

In Quad Cities Open, 208 Ill. 2d at 501, 804 N.E.2d at 501, a not-for-profit

corporation operated an annual golf tournament. The corporation sold admission

tickets for the tournament, and the proceeds from the tickets, less overhead, went to

charities such as American Red Cross and Special Olympics. Quad Cities Open, 208 Ill.

2d at 501, 804 N.E.2d at 501. “Charitable events often demand[ed] that a portion of the

revenue be devoted to overhead costs in order to make the event possible.” Quad Cities

Open, 208 Ill. 2d at 516, 804 N.E.2d at 510. For example, to hold a tournament, prize

money was needed for golfers, and funds were needed for cart paths, grandstands,

concession stands, scoreboards, and water wells. Quad Cities Open, 208 Ill. 2d at 502-

03, 804 N.E.2d at 502. Although only 7% of the corporation’s revenue between 1998

and 2000 went to charity, it was plausible that the corporation had to incur 93% of

overhead in order to generate the 7% of profit for charity. Quad Cities Open, 208 Ill. 2d

at 515-16, 804 N.E.2d at 509-10. As the supreme court said, “[a] charity is not defined

by percentages.” Quad Cities Open, 208 Ill. 2d at 516, 804 N.E.2d at 509. But it does

not follow that percentages are irrelevant. The disparity between overhead and charita-

ble expenditures can be so extreme that it would be disingenuous to maintain that such

a vast amount of overhead was incurred for the purpose of generating such a minuscule

amount of charity. See Winnebago Home, 40 Ill. 2d at 102, 237 N.E.2d at 539-40. The

– 27 –

Director could be skeptical that Covenant’s raison d’etre was the 0.7% of its revenue that

it devoted to charity care.

The other two cases, Cannon and Sisters of the Third Order, at least

involve hospitals, but they are distinguishable because all patients who were unable to

pay received charity: ” ‘charity was dispensed to all those who needed it’ ” (Cannon, 404

Ill. at 72, 88 N.E.2d at 23, quoting Sisters of the Third Order, 231 Ill. at 322, 83 N.E. at

274). In Sisters of the Third Order, 231 Ill. at 320, 83 N.E. at 273, “[t]hose who [were]

without money or property [were] cared for without charge,” and “[t]hose who [were]

able to pay [were] charged from $8 to $25 per week” so as to finance the care of the 5%

of the patients who were unable to pay (Sisters of the Third Order, 231 Ill. at 320, 83

N.E. at 273). Because Provena’s charity care program in 2002 considered only the

patient’s income relative to the federal poverty guidelines without considering the

amount of the medical bill or the patient’s other liabilities and Covenant devoted only

0.7% of its revenue to charity care, the Director could regard the program merely as a

pretense of charity, a pro forma procedure that was not calculated to make a serious

evaluation of need. Although Provena proved that it turned no patient away, it did not

prove that “[t]hose who [were] without money or property [were] cared for without

charge” (Sisters of the Third Order, 231 Ill. at 320, 83 N.E. at 273)–or so the Director

reasonably could have found.

b. The Relevance of Percentages, Despite the Impossibility
of an Across-the-Board “Quantitative Test”

In denying an exemption under section 15-65(a) (35 ILCS 200/15-65(a)

(West 2002)), the Director stated as follows:

– 28 –

”The primary basis of my conclusion is simple: Covenant

admitted that its 2002 revenues exceeded $113,000,000 and

that its charitable activities cost it only $831,724, or about

0.7% of total revenue. The property tax exemption it re-

quested was worth over $1,100,000. *** [T]o obtain the

exemption, Covenant was required to prove that its primary

purpose was charitable care. These financial figures fall

short of meeting the primary purpose standard.”

Provena argues as follows:

“[T]he Department’s insistence on a quantitative test is

simply indefensible. No [s]upreme [c]ourt decision adopts a

quantitative approach. No quantitative element appears

anywhere in the [Methodist Old Peoples Home] analysis.

And the [s]upreme [c]ourt has never pinned entitlement to a

charitable exemption on how much free care (or free any-

thing) an organization provides. On the contrary, the [c]ourt

has rejected such a quantitative test of charity at every op-

portunity. See, e.g., Sisters of the Third Order, 231 Ill. at

320, 322[,] [83 N.E.2d at 273-74] (rejecting the claim that

5% free patient care was too insubstantial to justify exemp-

tion); Quad Cities Open ***, 208 Ill. 2d [at] 515-516[,] [804

N.E.2d at 509] (same result for claim that 7% was insuffi-

cient to qualify as a charity).” (Emphasis in original.)

– 29 –

Section 6 of article IX does not speak of percentages; it speaks of “exclu-

sive use” (Ill. Const. 1970, art. IX, §6), which courts have interpreted as “primary use,”

and the primary use of property is quintessentially a factual question. Whether property

is exempt from taxation is highly dependent on the facts of each case. Lawrenceville v.

Maxwell, 6 Ill. 2d 42, 48, 126 N.E.2d 671, 675 (1955). The Illinois Hospital Association

says: “[T]he Department does not disclose the percentage that is required, only that

Provena’s is not enough.” The point is valid, but the “percentage that is required” was

not strictly necessary to the Director’s decision, any more than it was necessary to the

supreme court’s decision when it criticized the defendant in Winnebago Home, 40 Ill.

2d at 102, 237 N.E.2d at 539-40, for allocating “only sufficient funds to provide for one

needy applicant.”

A scholar criticizes the uncertainty Illinois law causes by its failure to

mandate a particular percentage of charity care. 37 Loy. U. Chi. L.J. at 514. But coming

up with a fixed percentage, applicable to all charitable hospitals, would be problematic.

As the supreme court long has held, a charitable institution may charge a fee to those

who are able to pay. Winnebago Home, 40 Ill. 2d at 101, 237 N.E.2d at 539. For most

hospitals, charging patients who are able to pay is, as a practical matter, a necessity.

Given the permissibility and necessity of charging those who are able to pay, the amount

of charity care a hospital provides may depend on how many impoverished people seek

treatment. Sisters of the Third Order, 231 Ill. at 322, 83 N.E. at 274 (“The institution

could not extend its benefactions to those who did not need them or to those who did

not seek admission”). As the Illinois Hospital Association explains, how many impover-

ished people seek treatment in turn would depend on a number of highly variable

– 30 –

factors, to which an across-the-board, fixed percentage would be unsuitable, e.g., the

type of hospital, local demographics, public health, the economy, the cost of medical

care, and the cost and availability of medical insurance.

Thus, in Sisters of the Third Order, 231 Ill. at 322, 83 N.E. at 273-74, the

“great disparity” between the patients who paid and the patients who were treated for

free did not necessarily negate the primary purpose of charity. It was conceivable that

only 11% of the patients who sought admission were unable to pay (5% of which the

hospital treated for free and the other 6% of which the hospital treated at the county’s

expense (Sisters of the Third Order, 231 Ill. at 320, 83 N.E. at 273)).

The wide variability of need from one community to another did not

prevent the supreme court from considering percentages or numbers in Sisters of the

Third Order, 231 Ill. at 320, 83 N.E. at 273, and German Hospital, 233 Ill. at 248-49, 84

N.E. at 216. In the latter case especially, the supreme court discussed at great length

“the facts found and certified in tabular form by the board of review as to the number of

patients received each year during the past five years, the number treated free, [and] the

number treated [at various discounted rates],” and the supreme court observed that “a

large proportion of the entire number of patients received are treated either free or at

less than actual cost.” German Hospital, 233 Ill. at 248, 84 N.E. at 216.

Common sense suggests that the number of charity patients a hospital

actually serves has direct relevance to one of the factors in Methodist Old Peoples

Homes, 39 Ill. 2d at 157, 233 N.E.2d at 542, namely, whether the hospital “dispenses

charity to all who need and apply for it.” Charity is more than rhetoric. The term

“charitable purpose” signifies “concrete, practical, objective charity, manifested by

– 31 –

things actually done for the relief of the unfortunate and the alleviation of suffering or in

some work of practical philanthropy.” In re Estate of Schureman, 8 Ill. 2d 125, 132-133,

133 N.E.2d 7, 11 (1956).

As the millions of Americans who cannot afford health insurance would

attest, hospitals afford ample opportunities for “some work of practical philanthropy”–

and nothing is more practical than numbers. Medical care has become ruinously

expensive. The cost of a hospital stay has been outpacing inflation for many years.

“Between 1971 and 1981, the cost of a hospital day increased 15[%] annually.” J. Lane,

The Impact of the Medicare Prospective Payment System and Recommendations for

Change, 7 Yale J. on Reg. 499, 501 (1990). “Estimated health care costs for 2005 exceed

$1.9 trillion, a 48% increase over the $1.3 trillion spent in 2000. These costs are nearly

4.3 times higher than our national defense spending and have been rising at least 50%

faster than the rate of inflation. Further, inpatient hospital costs have increased almost

50% in the last decade ***.” Fifth Annual Health Law & Policy Colloquium: Provider

Response to Cost Containment: An Insider Perspective, 15 Annals Health L. 387, 388

(2006). In 2001, 1,458,000 Americans filed for bankruptcy, and according to a recent

study, “about half of these filings had a medical debt cause, meaning that about 729,000

bankruptcy filings were caused by medical debt.” J. Colombo, Health Law Symposium:

Federal & State Tax Exemption Policy, Medical Debt & Healthcare for the Poor, 51 St.

Louis U. L.J. 433, 450 n.112 (2007). “[T]hese numbers do not include what is likely a

much larger number of families that avoided bankruptcy despite similar financial

problems.” 51 St. Louis U. L.J. at 450. The number of uninsured Americans rose to 45

million in 2003, up 1.4 million from 2002 (D. Nelson, Antitrust Modernization Comm’n

– 32 –

Goes to Work, 17 Loy. Consumer L. Rev. 121, 132 (2004)), and, according to one of the

amici, the American Hospital Association, the figure now is 47 million.

Against that backdrop of familiar facts, the Director found that in 2002,

Covenant spent only 0.7% of its revenue on charity care. The Director could have drawn

either of two inferences from that percentage. He could have inferred that in 2002,

medical care in Champaign County was so affordable, and the citizenry so prosperous,

that there simply was no occasion for Covenant to spend more than 0.7% of its revenues

on charity care; a higher percentage would have required Covenant to “manufacture

patients in need,” as Provena puts it. Alternatively, the Director could have inferred that

Covenant did not dispense charity to all who needed it and that Covenant, therefore, was

not used “exclusively” for “charitable purposes.” The Director chose the latter inference,

and we are not left with a definite and firm conviction that he thereby made a mistake.

If, in Winnebago Home, 40 Ill. 2d at 102, 237 N.E.2d at 540, the supreme court could

draw an adverse inference from the trivial amount of resources the defendant had

allocated for charity care, we do not see why the Director is precluded from drawing a

comparable inference in the present case.

c. Covenant’s Charity Care Policy

Applicant exhibit No. 29 is Covenant’s “Charity Care Policy” that was in

effect in 2002. The policy was approved on May 10, 1994. According to this policy,

“[t]he provision of necessary services by St. Mary’s Hospital shall not be withheld based

upon an individual’s ability to satisfy the related financial requirements.” (Covenant

used to be St. Mary’s Hospital.) In the case of a patient who did not obtain an advance

determination of his or her eligibility for charity care, Covenant would follow “normal

– 33 –

collection practices,” and “[a]t any time during the collection process,” the patient could

apply for charity care by contacting the patient accounting office. Persons whose family

income was above, but less than double, the poverty income guidelines set by the federal

government and whose assets other than a principal residence were $5,000 or less were

eligible for charity care. Those who qualified for charity care on the basis of their

income and whose equity in a principal residence was $10,000 and whose other assets

were $5,000 or less would be eligible for charity care after a determination of insurance

benefits.

Specifically, those whose income was less than the guidelines would be

eligible for a 100% reduction of the patient portion of the billed charges. Those whose

income was greater than the guidelines but not more than 1 1/4 times the guidelines

would be eligible for a 75% reduction. Those whose income was greater than the

guidelines but not more than 1 1/2 times the guidelines would be eligible for a 50%

reduction. Those whose income was greater than 1 1/2 times the guidelines but less

than double the guidelines would be eligible for a 25% reduction.

The poverty income guidelines for 2000 were as follows:

“Size of family unit

Poverty Guidelines

1

2

3

4

5

6

$ 8,350

11,250

14,150

17,050

19,950

22,850

– 34 –

7

8

25,750

28,650

For family units with more than 8 members[,] add $2,900

for each additional member.”

Those who qualified for charity care on the basis of income but who had assets above the

aforementioned levels would become eligible for charity care to the extent that collec-

tions of charges for services rendered reduced assets below the $5,000 and $10,000

thresholds.

In his decision, the Director found that Covenant’s charity care policy that

was in effect in 2002 “fail[ed] to dispense charity according to the [Methodist Old

Peoples Home] factors” because the policy “ignore[d] completely the financial burden

incurred by the patients or families for the medical services rendered.” The Director

gave the following example:

“[A] patient whose portion of billed charges was $50,000[]

and whose income was at a level allowing for a 50% waiver of

charges would be left with a $25,000 bill after application of

the sliding scale. It is unlikely that the patient or the pa-

tient’s family[,] in this situation[,] would ever be able to pay

off this bill, considering the level of income. A patient at the

same level on the poverty income scale with billed charges of

$1,000 would be left with an outstanding bill of only $500

after the sliding scale is applied. As the illustration demon-

strates, application of Covenant’s charitable policy would

– 35 –

result in an impoverished patient’s family being faced with

an unpaid bill 50 times higher than a patient at the same

level of poverty income[,] simply because of the billed

amount for the medical services rendered. A true charitable

care policy would be more meaningful and would result in a

fair evaluation of a patient’s ability to pay.

Put differently, it is clear that the patient whose billed

medical charges are $50,000 is much more in need of a

greater level of assistance from Covenant than the patient

whose billed charges are $1,000. Yet Covenant applies the

same 50% reduction in charges to both patients, having the

reduction only on the level of poverty income.

Moreover, during 2002, Provena Covenant referred

patients with unpaid charges to collection agencies, even

when a portion of the patient’s charges had been reduced

pursuant to the Charity Care Policy.”

This critique of Covenant’s charity care policy strikes us as reasonable. In

its disregard of liabilities, the charity care policy could have posed an obstacle to the

dispensation of charity to the needy. See Methodist Old Peoples Home, 39 Ill. 2d at 157,

233 N.E.2d at 542. Basically, the charity care policy lacked nuance. In simple terms of

the dollar amount of assets, an elderly retired person might have the means of paying

for a medical procedure, but he might have to liquidate his house and the investments

upon which he depends for basic survival. See B. Cohen, The Controversy Over Hospital

– 36 –

Charges to the Uninsured–No Villains, No Heroes, 51 Vill. L. Rev. 95, 102 (2006).

Apparently, such a person would be ineligible for charity care at Covenant.

Although Covenant had a policy of admitting everyone regardless of their

ability to pay, we will not assume that everyone availed themselves of that policy

regardless of their ability to pay. The prospect of a crushing financial liability could well

have been an obstacle in some people’s minds; it could have deterred them from

undergoing medical treatment.

In its brief, Provena argues it is undisputed that Covenant’s charity care

policy “is only a guide[] and is not mechanically applied” and that “a patient’s eligibility

for free care is always open to reassessment, even if a patient were originally determined

to be financially able to pay.” But the record does not seem to reveal how often Cove-

nant departed from the guidelines of its charity care policy, how often a reassessment

was done, what the reassessment considered, and how often a reassessment made any

difference (not often, one might infer, if out of 110,000 admissions, Covenant gave free

or discounted care to only 302 patients–and then hired a collection agency to contact 64

of those 302 charity care patients).

d. The Illusory Nature of Much of Covenant’s “Charity Care Costs”

The dollar amount of charity care can be measured in either of two ways:

(1) the cost to the hospital or (2) the amount the hospital charged. 37 Loy. U. Chi. L.J. at

511. If cost is used, it can be either average cost, which includes overhead, or it can be

marginal cost. 37 Loy. U. Chi. L.J. at 511. Section 20(3) of the Community Benefits Act

requires hospitals to report their charity care as measured by average cost: the “actual

cost of services provided, based on the total cost[-]to[-]charge ratio derived from the

– 37 –

hospital’s Medicare cost report.” 210 ILCS 76/20(3) (West 2006). Marginal cost is the

excess cost of treating an additional patient. See 37 Loy. U. Chi. L.J. at 511 n.111. For

example, if treating 10 patients costs the hospital $10,000 but treating 11 patients costs

the hospital $10,500, the marginal cost of treating the eleventh patient is $500. The

average cost of treating all 11 patients is $10,500 divided by 11, or about $954. See 37

Loy. U. Chi. L.J. at 511 n.111. Measuring charity care by charges yields a higher dollar

figure than measuring by cost; and measuring by average cost yields a higher dollar

figure than measuring by marginal cost. 37 Loy. U. Chi. L.J. at 511.

A scholar lays out the case for average costs as follows:

“[A]s a matter of theory, using charges to measure

charity care is patently ridiculous. In this regard, hospitals

operate akin to hotels, which have a ‘rack rate’ for their

rooms. Like the rack rate on hotel rooms, virtually no one

actually pays the hospital’s ‘rack rate’ for services; instead,

hospitals negotiate discounted reimbursement rates with

insurance companies, or such rates are set by the govern-

ment as part of the Medicare and Medicaid program. Using

charges as the measure of charity care, therefore, would

simply let hospitals inflate their charity care ‘numbers’ by

setting higher prices for services that they know will never be

collected, or if collected at all, are charged only to uninsured

patients. ***

As between average and marginal cost measures, a

– 38 –

good case can be made for either. The argument for mar-

ginal costs is that in the short run, filling empty beds with

charity patients or taking a few extra x-rays with a machine

already paid for costs very little[] and hospitals should not be

‘credited[,]’ in the charity care ledger[,] with part of their

overhead and capital investment in providing these services,

since those investments would have to be made anyway for

paying patients. Over time, however, nonpaying patients

represent a more or less permanent burden on a hospital and

will eventually require replacement of assets sooner than

would have been the case if the charity patients had not been

served. Thus, average costs (e.g., including overhead and

depreciation in the cost number) represent a better ‘true’

measure of charity care in the long run. Average costs, in

fact, are the measure that most academics use in measuring

the value of charity care. Also, average costs are the measure

used by a number of states in legislation relating to charity

care reporting, including the recently enacted Community

Benefits Act in Illinois [(210 ILCS 76/1 through 99 (West

2006))] (although states have also used the marginal cost

measure in some circumstances).” 37 Loy. U. Chi. L.J. at

511-13.

We find this reasoning to be persuasive. In addition, we note that in German Hospital,

– 39 –

233 Ill. at 248, 84 N.E. at 216, the supreme court seemed to quantify charity care by its

cost (“a large proportion of the entire number of patients received are treated either free

or at less than actual cost”). And, again, in section 20(3) of the Community Benefits Act

(210 ILCS 76/20(3) (West 2006)), the legislature designated average cost as the

measure of charity care.

In 2002, pursuant to its charity care policy, Covenant treated some

patients for free and discounted its bills for other patients. Apparently, in calculating

the amount of its charity care, Covenant used the average cost of the discounted

portions of the bills. The Director stated:

“The applicant has asserted in several different contexts that

the cost of waiving charges pursuant to its charity care policy

in 2002 was $831,724 [citations to record] while the revenue

it waived amounted to $1,758,940 [citations to record]. To

obtain the cost figure, the [a]pplicant took the total cost of

providing care in the hospital and the total billed amounts

and developed a cost[-]to[-]charge ratio. The ratio was

applied to the charges generated. [Citations to record.]

$1,758,940 divided by $831,724 equals 2.1148.”

As the Director explained, in the case of a patient whose bill Covenant

discounted by 50%, the markup inherent in the remaining 50% more than consumed

the charity care in the 50% discount, if charity care were measured by average cost. The

Director reasoned as follows:

” [A] patient entitled to a 50% waiver based upon her

– 40 –

level on the poverty income scale[] and who received a

$50,000 bill would be left with a $25,000 balance after

application of the sliding scale reduction. This $25,000

outstanding bill, if paid by the patient, actually would have

generated an average mark[]up of $1,358 for Covenant.

($50,000 divided by 2.1148 equals $23,642. The difference

of $1[,]358, based upon Covenant’s formula, apparently

would have been the margin above its costs for the preferred

service.) It is impossible to conclude that this policy truly is

charity as contemplated by the [Methodist Old Peoples

Homes] guidelines. Thus, *** the Department’s counsel

would appear to be correct in characterizing this practice as

‘the illusion of charity.'”

Thus, it would appear that in the case of the patients whose bills Covenant discounted by

50% or 25%, Covenant actually came out ahead (at least, in terms of what the patients

owed) and, therefore, extended no charity at all to those patients. The figure of

$831,724, small as it is relative to Covenant’s total revenues, appears to be an exaggera-

tion.

e. Shortfalls in Medicare and Medicaid

Applicant exhibit No. 64 is entitled “Provena Covenant Medical Center

Charitable Contributions [in] 2002,” and it lists the following two items, among others:

2. Medicaid Subsidy @ Cost

$3,105,217

“Cost

– 41 –

3. Medicare Subsidy @ Cost

$7,418,217.”

The First, Second, and Third Districts have held that writing off “bad debt”

is not charity. Alivio Medical Center v. Department of Revenue, 299 Ill. App. 3d 647,

652, 702 N.E.2d 189, 193 (1998); Highland Park Hospital v. Department of Revenue,

155 Ill. App. 3d 272, 280, 507 N.E.2d 1331, 1336 (1987); Riverside Medical Center v.

Department of Revenue, 342 Ill. App. 3d 603, 609, 795 N.E.2d 361, 366 (2003). One

commentator disagrees with these decisions. 37 Loy. U. Chi. L.J. at 513. He maintains

that Medicaid reimbursements (and, presumably, also Medicare reimbursements) that

“fail to fully cover average costs” “probably should count as charity care because this

represents a net cash outflow.” 37 Loy. U. Chi. L.J. at 512. He reasons as follows:

“One can certainly sympathize with the view that from the

standpoint of the patient, being accepted for treatment with

an up-front guarantee that the hospital will not seek pay-

ment is better than being billed for treatment and hounded

by collection efforts, even if the ultimate result (no payment)

is the same. But from the standpoint of the hospital, both

scenarios result in a lack of payment that the hospital must

make up for elsewhere to stay financially viable, and there is

little doubt that a significant portion of bad debt is in fact

related to the patient’s financial inability to pay ***. *** At

some point, if government keeps piling on uncompensated

care obligations without some kind of offsetting revenue

enhancement, the hospital will simply no longer be able to

– 42 –

operate. Thus, an absolute rule that bad debts do not ‘count’

as part of the justification for exemption also seems wrong

despite the courts’ conclusions.” 37 Loy. U. Chi. L.J. at 513.

Initially, we note that “treatment of Medicare and Medicaid patients [is] a

virtual requirement” for exemption from the federal income tax (37 Loy. U. Chi. L.J. at

498, citing IHC Health Plans, Inc. v. Commissioner of Internal Revenue, 325 F.3d 1188,

1197-98 (10th Cir. 2003)), as the American Hospital Association candidly admits.

Further, from a legal point of view, we disagree with the reasoning that just because the

end result of bad debt and charity is the same (lack of payment to the hospital), bad debt

should be considered charity. If an organization could acquire a tax exemption for

giving up on collecting from deadbeat customers, nearly every business in Illinois would

be tax-exempt.

As we have explained, charity from one person to another is a gift.

Perhaps it is possible to give someone a gift in the form of forgiveness of debt, but to

accomplish that gift, one surely would have to do more than write off the debt. Writing

off a patient’s bad debt involves only the hospital and its databases. Vis-a-vis the

hospital and the patient, the relationship of creditor and debtor remains intact–and,

presumably, the patient will conduct his affairs accordingly; he might forego opportuni-

ties, and, generally, he will live under a cloud, assuming that everything he owns and

acquires could eventually be subject to execution. See 51 Vill. L. Rev. at 102. In fact, the

ALJ found that “[i]f a patient [paid] an amount on an account that was included in

[Covenant’s] bad debt expense, then the payment [was] recorded as a recovery to bad

debt.” And so nothing really has changed between the patient and the hospital. The

– 43 –

hospital merely has decided, for its own accounting purposes, that trying to enforce the

debt would be futile or economically unrewarding–hardly a decision that exudes the

“warmth and spontaneity indicative of [a] charitable impulse” (Willows, 43 Ill. 2d at

208, 251 N.E.2d at 252).

Because a gift is, as we have explained, an uncompensated transfer, the

hospital cannot be someone’s creditor with respect to a certain sum and simultaneously

be the person’s charitable benefactor with respect to that same sum. A decision about

the futility of collection that a creditor makes in the privacy of his office does not vitiate

the contractual relationship between the creditor and debtor. Like any other gift, a gift

in the form of forgiveness of debt requires some kind of delivery. Berry v. Berry, 238 Ill.

App. 507, 510 (1925); Restatement (Second) of Contracts §§274, 277(1), at 366, 370

(1981); 38 Am. Jur. 2d Gifts §45 (2008). Further, the supreme court has held:

“[W]here there is no proof of consideration for the forgiveness of a debt, an attempt to

forgive a debt is ineffective either as a gift or as an executory contract.” Ermold v. Bear,

358 Ill. 233, 238, 193 N.E. 184, 186 (1934); see also Restatement (Second) of Contracts

§273, at 364 (1981). It appears that once a hospital enters into a contract with a patient

whereby the patient agrees to pay for services, transforming that patient into a charita-

ble beneficiary is somewhat more complicated, legally, than simply making a notation in

the hospital’s accounts. Provena has not explained how, from a legal point of view, this

transformation would have come about. See A. Noble & A. Hyams, Charitable Hospital

Accountability: A Review and Analysis of Legal and Policy Initiatives, 26 J.L. Med. &

Ethics 116, 119 n.66 (1998) (“American Association of Certified Public Accountants

issued updated health care audit guidelines in 1990,” under which “hospitals must now

– 44 –

segregate bad debt from charity care on their financial statements. Bad debt is now

reported as an expense. Charity care, considered services provided without expectation

of payment, is reported as a footnote on the financial statement”).

We understand that probably half the time, the reason for default is that

the patient simply cannot pay. 37 Loy. U. Chi. L.J. at 513 (“Some academic studies have

shown that roughly 50% of hospital bad debt is likely due to inability to pay, rather than

simply debt avoidance or poor management”). According to the ALJ’s findings,

approximately 60% of Covenant’s inpatient admissions originate through the emergency

room–probably not an ideal place for a careful and methodical assessment of someone’s

financial situation. We can envision an argument that referral to a collection agency is

part of the procedure of charity care. Through the services of the collection agency,

Covenant assesses the extent of the patient’s financial need, and once the collection

agency validates the patient as an impoverished person, Covenant writes off the debt,

and the write-off is charity. Setting aside the obstacle posed by Ermold, the main

problem with this argument is that Covenant continued to accept payments on what

Covenant had designated, purely in its accounts, as bad debt.

We do not mean to put Covenant in a bad light simply because it uses

collection agencies. There is nothing wrong, per se, with a charitable organization using

collection agencies and even lawsuits to collect what is owed to it. As we have discussed,

charitable organizations may enter into contracts with those who are able to pay. It

would be illogical to say, on the one hand, that a charitable organization may enter into

a contract and, on the other hand, to forbid the charitable organization from insisting on

the performance of the contract. The resources of a charitable organization are finite,

– 45 –

and those who fail to pay, even though they could pay without suffering economic

hardship, effectively use resources that otherwise might have gone to the poor. In our

mind, the only relevance of Covenant’s sending accounts to collection agencies is the

negation of a charitable relationship with respect to the balances in those accounts. In

2002, Covenant sent 10,085 accounts to collection agencies but gave charity care to only

302 patients. Not all those 10,085 accounts, or maybe not even most of them, origi-

nated from 2002, but the vast disparity between those numbers could strike a reason-

able trier of fact as significant. As Provena says in its brief, there could be a variety of

reasons for patients’ failure to pay. One of the foremost reasons, however, surely would

be an inability to pay. The Director could reasonably infer that a lot of patients were not

receiving charity care who needed it.

f. The Significance of the Stipulations

Provena argues that because the Department stipulated that Covenant

“dispenses health care to all who apply for it,” “regardless of their ability or inability to

pay for the service,” it is established, as a matter of law, that Covenant provides charity

to all who are in need. See In re Marriage of Sanborn, 78 Ill. App. 3d 146, 149, 396

N.E.2d 1192, 1195 (1979) (“[p]arties are bound by their stipulations”). This is a non

sequitur. Just because Covenant never turns a patient away because of the patient’s

inability to pay, it does not follow that Covenant thereby provides charity. If, despite the

patient’s inability to pay, the patient is contractually liable to reimburse Covenant for

the medical treatment, Covenant has extended no charity to that patient.

g. Off-Site Charity

In applicant exhibit No. 64, entitled “Provena Covenant Medical Center

– 46 –

Charitable Contributions [in] 2002,” Provena alleges that Covenant made the following

charitable contributions (other than charity care and the Medicaid and Medicare

subsidies, which we have already discussed):

4. Crisis Nursery Services & Support

$ 25,851

5. Volunteer (community benefit) classes/ $189,509
services

“Cost

6. Emergency Medical Services (training & $173,228
support to community and area agencies)

7. Charitable subsidy on ambulance service $888,091

8. Donations to Other Not-for-Profits $ 54,370
(less value of participation)

9. Behavioral Health community benefit $374,537

10 Subsidy for graduate medical education $531,688.”

It is unclear to us that these items, admirable as they are, describe uses of

the subject property as opposed to uses of income from the subject property or uses of

other property. “The use to which the property is devoted is decisive rather than the use

to which income derived from the property is employed.” City of Lawrenceville, 6 Ill. 2d

at 49, 126 N.E.2d at 676. “[P]roperty which is used to produce income to be used

exclusively for charitable purposes may not be exempted from taxation, the test being,

instead, the present use of the property rather than the ultimate use of the proceeds

derived from the property sought to be exempted.” Goodman, 388 Ill. at 374, 58 N.E.2d

at 39. “Whether or not [a hospital] is a charity is to be determined by the treatment

which the patients receive at the hands of those in charge of the hospital.” Sisters of the

– 47 –

Third Order, 231 Ill. at 323, 83 N.E. at 274. See also Midwest Physician Group, Ltd. v.

Department of Revenue, 304 Ill. App. 3d 939, 957, 711 N.E.2d 381, 393 (1999) (exemp-

tion depends on activities “on the property”); Congregational Sunday School, 290 Ill. at

118, 125 N.E. at 11 (“It is not the use to be made of the profits but the nature of the

business done that is to be considered in deciding the question of liability to taxation”).

In this respect, the Illinois standard for exemption from property taxes is different from

the more diffuse “community benefit” standard for exemption from the federal income

tax. See Rev. Rul. 69-545, 1969-2 C.B. 117-18; 37 Loy. U. Chi. L.J. at 497-98.

The ambulance service (item No. 7), for example, undoubtedly benefits the

community, and, therefore, we assume it counts for purposes of the federal income-tax

exemption. But Illinois law scrutinizes the use of the subject property, and we do not

know where the ambulances are garaged. Do they depart from Covenant and bring

patients back, or are they dispatched from a separate address? The Department

suggests, with citations to the record, that the majority of people transported by the

ambulances appear to be covered by third-party payers such as Blue Cross, the Civilian

Health and Medical Program of the Uniformed Services (CHAMPUS), and health

maintenance organizations. Provena does not disagree. It is unclear to what extent the

$888,091 for this item consists of the “shortfall” resulting from the discounted rates that

insurers paid. Such discounts would not be charitable. See Riverside Medical Center,

342 Ill. App. 3d at 610, 795 N.E.2d at 367.

C. The Exemption for Religious Purposes

1. The Constitutional and Statutory Provisions

Section 6 of article IX of the Illinois Constitution of 1970 allows the

– 48 –

General Assembly to exempt “property used exclusively for religious *** purposes.” Ill.

Const. 1970, art. IX, §6. Section 15-40 of the Property Tax Code provides as follows:

“(a) Property used exclusively for:

(1) religious purposes ***

* * *

qualifies for exemption as long as it is not used with a view to

profit.” 35 ILCS 200/15-40(a)(1) (West 2002).

2. Forfeiture

In the application for exemption that it filed in December 2002, Provena

never claimed an exemption for religious purposes (35 ILCS 200/15-40(a)(1) (West

2002)); it claimed an exemption only for charitable purposes (35 ILCS 200/15-65(a)

(West 2002)). Because the county board of review never had an opportunity to consider

whether Covenant qualified for an exemption for religious purposes, the Department

argues that Provena failed to exhaust its administrative remedies and is barred from

invoking section 15-40(a)(1) on appeal. See In re Application of County Collector of Du

Page County, 157 Ill. App. 3d 355, 361, 510 N.E.2d 1240, 1244 (1987). Provena responds

that the Department has forfeited the defense of failure to exhaust administrative

remedies, because the Department failed to raise that defense in circuit court. See In re

Application of Aurand, 90 Ill. App. 3d 560, 565, 413 N.E.2d 161, 165 (1980). We agree

with Provena. We further note that in his decision, the Director addressed the substan-

tive merits of Provena’s claim of an exemption for religious purposes.

3. The Effect of the Stipulations

In the administrative proceedings, the Department stipulated that

– 49 –

”Covenant’s stated and ongoing mission is to serve as the Catholic health[-]care ministry

and charitable hospital in the Champaign/Urbana area and to build communities of

healing and hope by compassionately responding to human need in the spirit of Jesus

Christ” and that Covenant was “founded, organized, owned[,] and operated as an

apostolic mission and health[-]care ministry of the Catholic Church.”

According to Provena, these stipulations compel a determination that

Covenant is exempt under section 15-40(a)(1) (35 ILCS 200/15-40(a)(1) (West 2002)).

We disagree. It is Covenant’s actual practice, not merely its mission, which determines

the right to exemption. See Methodist Old Peoples Home, 39 Ill. 2d at 157, 233 N.E.2d

at 542. The issue is not whether Covenant is operated as an “apostolic mission and

health care ministry of the Catholic Church” but whether it is “used exclusively for ***

religious purposes” as case law defines that phrase. See 35 ILCS 200/15-40(a)(1) (West

2002). The stipulations do not squarely address that issue.

If “religious purpose” meant whatever one did in the name of religion, it

would be an unlimited and amorphous concept. Exemption would be the rule, and

taxation the exception. “In a sense, everything a deeply devout person does has a

religious purpose.” Faith Builders, 378 Ill. App. 3d at 1046, 882 N.E.2d at 1264. In

Fairview Haven v. Department of Revenue, 153 Ill. App. 3d 763, 768-69, 506 N.E.2d

341, 345 (1987), we were unpersuaded by the reasoning that a nursing home had a

religious purpose because taking care of the elderly was a way of “tying preaching to

action.” “Religious purpose” within the meaning of section 15-40(a)(1) (35 ILCS

200/15-40(a)(1) (West 2002)) has to be narrower than “Christian service,” or else

“religious purpose” would mean everything (and, therefore, nothing). In People ex rel.

– 50 –

McCullough v. Deutsche Gemeinde, 249 Ill. 132, 136-37, 94 N.E. 162, 164 (1911), the

supreme court stated: “[A] religious purpose means a use of such property by a religious

society or body of persons as a stated place for public worship, Sunday schools[,] and

religious instruction.” In People ex rel. Carson v. Muldoon, 306 Ill. 234, 238, 137 N.E.

863, 864 (1922), overruled in part on other grounds by McKenzie v. Johnson, 98 Ill. 2d

87, 100, 456 N.E.2d 73, 79 (1983), the supreme court said, with reference to the quoted

passage from Deutsche Gemeinde: “This was not stated as inclusive of everything that

might in the future be regarded as a use for religious purposes but as illustrative of the

nature of such use.” If, as Muldoon said, public worship, Sunday schools, and religious

instruction are “illustrative of the nature of [religious] use,” it must follow that “religious

use” has a determinable nature and that to be a religious use, the activity must somehow

resemble the activities listed in Deutsche Gemeinde. We do not see how medical care

resembles public worship, Sunday schools, or religious instruction. Cf. Calvary Baptist,

349 Ill. App. 3d at 327, 812 N.E.2d at 2 (throughout the year, the property was used for

Bible study classes, teen ministry events and meetings, and devotional activities, with

occasional and incidental secular events).

4. Primacy of the Use

Provena had to prove that the religious use of the property was primary

and that any secular use was incidental. See Fairview Haven, 153 Ill. App. 3d at 774, 506

N.E.2d at 349. If the operation of the property is businesslike and more characteristic of

a place of commerce than a facility used primarily for religious purposes, the property is

not exempt from taxation under section 15-40(a)(1) (35 ILCS 200/15-40(a)(1) (West

2002)). Faith Builders, 378 Ill. App. 3d at 1046, 882 N.E.2d at 1264. In 2002, more

– 51 –

than 99.99% of Covenant’s patients entered into contracts to pay for their medical

treatment. Almost all of Covenant’s $115 million in revenue came from insurance

companies, persons paying for their own treatment, and other contractual sources.

Donations totaled only $6,938. See Cook Communications Ministries v. Department of

Revenue, 345 Ill. App. 3d 753, 762, 803 N.E.2d 524, 530 (2004). Covenant sent 10,085

accounts to collection agencies in 2002. The record does not appear to reveal how often

theological instruction was given during the 110,000 admissions that year, but Covenant

spent $813,694 on advertising. Covenant more resembles a business with religious

overtones than property used primarily for religious purposes. See Cook Communica-

tions Ministries, 345 Ill. App. 3d at 758, 803 N.E.2d at 527; Fairview Haven, 153 Ill.

App. 3d at 775, 506 N.E.2d at 349; Faith Builders, 378 Ill. App. 3d at 1046, 882 N.E.2d

1264.

D. Considerations of Public Policy

The amici warn that adverse social consequences will follow if we reverse

the circuit court’s judgment and affirm the Director’s decision. They say that with the

number of uninsured Americans increasing and governmental programs failing to keep

up with the rising cost of health care, not-for-profit hospitals already operate on thin

margins. The loss of the tax exemption would make these hospitals less attractive to

lenders and would create a perverse economic incentive for the hospitals to shift

resources away from community needs other than free or discounted medical care.

Because not-for-profit hospitals have no funds to spare, they would have no choice but

to pass on to patients and commercial insurers the added cost of property taxes, and to

the extent they were unable to do so, they would have to cut services or even close their

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doors, swelling the ranks of the uninsured and burdening the state with the indigent

patients whom the hospitals formerly served, to the detriment of their bottom line.

These are arguments of public policy, and it is the legislature’s job, not

ours, to make public policy. Board of Education of Dolton School District 149 v. Miller,

349 Ill. App. 3d 806, 811, 812 N.E.2d 688, 693 (2004). Instead, we strive to be faithful

to the meaning of legislation and case law; and if these authorities, correctly interpreted,

do not readily apply to the modern polycorporate hospital, so be it. Just because the test

for exemption is, in some respects, “anachronistic, a reflection of a time without

third[-]party pay[e]rs and sophisticated medical care[,] *** it does not necessarily follow

that the changed circumstances still merit a tax exemption. Instead, perhaps the

exemption is as anachronistic as the reasons that originally gave rise to it. Things that

were once tax-exempt can become taxable if circumstances change.” 16 Am. J.L. & Med.

at 379.

In several jurisdictions, the decisions of which the American Hospital

Association cites, the concept of “charity” has become so amorphous and so tractable as

to be virtually devoid of meaning. “A word that comes to mean everything in effect

means nothing[ at all].” 31 Wm. Mitchell L. Rev. at 211. The term “charity” has become

magical gibberish to sanctify any socially beneficial use of property that a court deems

worthy of subsidy. But our constitution already enumerates the uses of property that

are categorically worthy of exemption–e.g., schools, cemeteries, agricultural and

horticultural societies–and hospitals are not among them. Ill. Const. 1970, art. IX, §6.

If, under section 6 of article IX, property used for “charitable purposes” is simply

property that is put to some publicly beneficial purpose, why would it be necessary to

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separately list schools, for instance, and agricultural societies, which obviously use

property in a publicly beneficial way by defeating ignorance and hunger? The way the

constitutional provision is phrased, it does not list schools and agricultural societies as

examples of charitable purposes ( by saying “and other charitable purposes” or words to

that effect).

As one commentator explains, the slippage of the meaning of “charity”

began long ago, when the Statute of Charitable Uses (43 Eliz. 4 (1601)), codifying

developments in the English common law, expanded the meaning of “charity” beyond its

“commonly understood definition of economic relief for the poor,” “to encompass

virtually anything deemed to be in the public interest.” 31 Wm. Mitchell L. Rev. at 191-

93. Because the Statute of Charitable Uses became part of Illinois common law (Conti-

nental Illinois National Bank & Trust Co. v. Harris, 359 Ill. 86, 90, 194 N.E. 250, 252

(1934); 5 ILCS 50/1 (West 2006)), the supreme court has held that ” ‘[c]harity,’ in the

legal sense, is not confined to mere alms[]giving or the relief of poverty and distress but

has a wider signification, which embraces the improvement and promotion of the

happiness of man” (Harris, 359 Ill. at 92, 194 N.E. at 253). But it is impossible to miss

the recurrent theme of charity care in the supreme court’s decisions on the exemption of

hospitals from taxation. It is as if the supreme court decided, early on, to resist any

further dilution of the meaning of “charity,” by holding that improving and promoting

the happiness of man entailed dispensing charity care as needed. See Sisters of the

Third Order, 231 Ill. at 322, 83 N.E. at 274 (“so long as charity was dispensed to all those

who needed it and who applied therefor”).

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The language we use in the State of Illinois to determine whether real

property is used for a charitable purpose has its genesis in our 1870 constitution. It is

obvious that such language may be difficult to apply to the modern face of our nation’s

healthcare delivery systems. Even the seminal case in Illinois, Methodist Old Peoples

Home v. Korzen, was decided when Medicare was in its infancy and Medicaid did not

yet exist. The capital needs of a properly equipped modern hospital were not even

imaginable in 1965. It is of obvious public benefit for any community to have available

one or more modern hospitals, but until such time as the legislature sees fit to either

change or make definite the formula for the determination of the medical/charitable use

of real property, Provena cannot, on the record before us here, prevail in its attempt to

exempt itself from real estate taxation.

III. CONCLUSION

For the foregoing reasons, we reverse the circuit court’s judgment.

Reversed.

McCULLOUGH and KNECHT, JJ., concur.

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